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Posts Tagged ‘smoking’

by Martin McKeeProfessor of European Public HealthLondon School of Hygiene and Tropical Medicine

Anyone walking through London’s King’s Cross station this week could be forgiven for thinking they had been transported mysteriously to somewhere else. Not, in this case, on the well trodden (albeit fictional) path by way of platform 9¾ on the Hogwart’s Express but rather to an earlier time, when cigarette advertisements were still legal. All along the stairways are pictures of what seemed to be cigarettes set against a soothing, healthy-looking blue background yet when you got up close you realised that they were actually Nicolites. The mistake is easily made. Indeed, the manufacturers take pride in the fact that their products are “designed to look and feel like real cigarettes”, which they certainly do.

As one branding expert said about an advertisement for E-lites, a competing brand, “everything about the ad and the way it’s targeted and it’s marketed to people does appear to be just like cigarettes”. With both products, the white barrel containing the battery looks just like the tobacco containing part of a cigarette, complete with a LED at the end that lights up when the user inhales. The nicotine container looks just like a filter tip. The marketing strategy is clearly working. Nicolites’ manufacturers advertise it as “the UK’s favourite electronic cigarette”, a claim seemingly borne out by independent sales data showing that their various brands account for six of the top selling brands of e-cigarettes sold in independent shops.

Yet e-cigarettes didn’t always look like the real thing. The early ones were quite different. Mechanical devices looking like something you might find under the bonnet of a car, with names that reflected their strange design, such as sonic screwdrivers, named after the instruments used by Dr Who. There was no risk that anyone would confuse them with a real cigarette. And just like Dr Who, these strange devices have attracted a remarkably dedicated group of supporters, as I discovered recently when I wrote a BMJ article on e-cigarettes. The article came about following the 2013 WHO European Regional Committee, where ministers from many of the smaller European countries were discussing the advertising blitz they were experiencing from the manufacturers of e-cigarettes (the ones looking like the real thing).

I did some homework and it rapidly became clear that the tactics used to market these so-called cig-a-likes were exactly the same as those used by the tobacco industry. These featured prominently highly sexualised advertisements and references to celebrity users, such as Katy Perry, Leonardo DiCaprio, Kate Moss and Lindsay Lohan. The e-cigarettes often contained flavours known to attract children, whether in cigarettes or alcopops, such as bubble gum. I heard from colleagues in several countries of new outlets springing up outside schools.

In my paper, I recognised that, just like any nicotine delivery device, e-cigarettes could play a role in helping people quit, although as most quitters succeed unaided, it is likely to be quite minimal, and anyway, the latest evidence from a New Zealand randomised controlled trial showed that they were no more effective than patches. But that wasn’t the point. The real issue was the way that these products, “designed to look and feel like real cigarettes” offered a means to get round advertising bans and to counteract one of the most effective measures against smoking, the campaign to denormalise it.

This had been so successful that those celebrities who did smoke would conceal it. Yet, as was already becoming clear, some were willing to be seen vaping, the term used to describe using e-cigarettes. And of course, e-cigarettes, if allowed to be used in public spaces, would undermine the remarkable success of smoking bans that have been policed by popular consent as bar staff would have to constantly check whether what someone was using was the real thing or an electronic copy.

I didn’t call for them to be banned. I simply called for them to be regulated just like other nicotine delivery devices and for advertising to be banned. In the light of what I have subsequently learned, I would add three more requirements. First, no company (including subsidiaries) should be able to manufacture both e-cigarettes and real ones. Second, they should not be designed to look like the real thing. And third, they should not be allowed to be used anywhere smoking is banned.

The response to my paper was remarkable. Within an hour of it being posted on the BMJ website I was the subject of dozens of messages on twitter. Most portrayed me as an idiot, but a significant minority believed I was evil (or both, calling me a “vile cretin”). I had absolutely no idea of the ability of those promoting e-cigarettes to mobilise so quickly and effectively!

So what had I done to upset them? Well, the main criticism was that the e-cigarettes I, and my colleagues at the WHO meeting were seeing advertised everywhere were not real e-cigarettes. Those attacking me sent dozens of pictures of the metallic contraptions they used, none of which looked anything like a cigarette. Indeed, the abiding impression is of what one might see if anyone ever created a museum of spark plugs. They also sent testimonies of how e-cigarettes had helped them cut down or quit smoking. Leaving aside the abusive tone of most of the messages, I was perfectly willing to accept what they said. They obviously did use these devices and I am sure that some of them found that they helped them to quit, even though I was equally sure that there were many more people who had quit without them.

When faced with such sustained criticism, it is important to reflect on whether you might be wrong. I put the term “e-cigarettes” into Google Images and, lo and behold, the vast majority of pictures were just like the ones I had seen advertised. There were a few of the mechanical devices, but only a very few. Then, some of my Twitter followers helpfully send me pictures of e-cigarettes being advertised in other countries. They also looked like the real thing. In some of the pictures, however, you did have to look hard as they were placed just beside the candy shelves, exactly where you would expect a kid to look.

The tide of abuse continued for several days. These things happen when you stand up for public health. But then something strange happened. Someone created a web page with a picture of me, subtly changed with reds, yellows and pseudo Cyrillic font, to look like a Soviet leader. They warned that I was “eliciting howls of rage from the vaping community, McKee is attempting to show vapers in the poorest possible light. Thuggish neanderthals who lack the wit, intelligence and willpower to abandon their filthy addiction to nicotine. Foul-mouthed fake smokers who will launch personal attacks upon a widely respected public health professional. It’s crude, but it can also be effective.” It was as if I had laid a trap into which they had fallen. If only I was so clever!

So what do I conclude from this experience? There is clearly a dedicated, highly vocal community using devices that look nothing like cigarettes. Many of them are, doubtless, deeply committed to harm reduction, but I argue that they miss the much bigger picture. However, given what we know about the tobacco industry, now that it has jumped on the e-cigarette bandwagon, it would be foolish to ignore the possibility that some of those responding with such speed and intensity to any challenge to e-cigarettes represent industry-manufactured Astroturf rather than spontaneously emerging grassroots.

Second, there are many small-scale manufacturers of these devices, some of whom almost certainly came into the business because they want to help people quit, although others probably saw the opportunity to turn a quick profit. But, with all due respect to these groups (even if it is not reciprocated), they are essentially irrelevant in the greater scheme of things. Big Tobacco once saw e-cigarettes as a trivial issue, given the work they had done to perfect the real thing as a product designed to attract kids. However, in the past year that has changed completely. It has spotted the new opportunities to circumvent advertising bans, via brand stretching and ambiguous imagery, and to renormalize actions that look for all the world like smoking.

Altria, the owner of Philip Morris USA, has just launched its first e-cigarette, MarkTen, using a subsidiary company. R.J. Reynolds has launched its new e-cigarette, Vuse. Lorillard acquired Blu Ecigs, one of the market leaders in the US and is expanding outlets rapidly. The small companies that initiated the manufacture of e-cigarettes will be swallowed up, as in every other field of commerce, and e-cigarettes will simply be a marketing extension of the real thing.

What is the best way to advocate and improve public health policy? Quietly and diplomatically, or through loud and public protest? Or is there room for both approaches?

These are some of the questions that are part of the discussion that led to the Faculty of Public Health’s (FPH) recent decision to withdraw from the government’s Responsibility Deals, a group drawn from industry, local authorities and the public health community.

The aim of the responsibility deal was to provide a quicker means of improving public health policy than bringing new legislation before parliament. The logic was that a ‘carrot not stick’ approach would lead to faster progress than forcing companies to meet new legal requirements. Participating organisations signed up to pledges on public health issues such as physical activity, taking a billion units of alcohol out of circulation or reducing calories in food.

FPH had representatives on the alcohol, food, physical activity and health at work networks until July 2013. We owe a debt of thanks to those FPH representatives who gave up their time to challenge decision-making and question the logic of the direction public health policy was taking. We can be sure that their input has helped mitigate some of the worst excesses of a commercial need to put the value of shares ahead of public health.

FPH’s decision to join the responsibility deal was controversial and much debated throughout the past two years. There are many people within the public health community who disagreed with our participation. Others felt it was better to be at the table, than to leave the debate unchallenged by public health expertise.

Given how public health policy has developed in recent years, the available options for effective advocacy have sometimes seemed like the moment in the film Argo when CIA officer Jack O’ Donnell has to admit that the ludicrous-sounding plan to rescue American hostages in Tehran, by pretending they are the crew of a sci-fi fantasy movie, is the ‘best bad idea’ he has.

Unlike the fictional and public world of a Hollywood film, much of public health advocacy goes on in a less public fashion. It has become clear that government public health policy has fallen victim to a concerted and shameful campaign of lobbying by sections of the tobacco and drinks industry who are putting profits before health and public safety.

The balance of gains and losses of participating in the responsibility deals shifted recently when the Government made it clear that a minimum unit price for alcohol and standardised packs for cigarettes would not be introduced.

In light of this, we withdrew from all of the Responsibility Deal groups. Using legislation to bring in measures like minimum unit pricing would have been quicker than a ‘softly softly’ approach. There is also no way of knowing if the responsibility deals have been truly effective because it is unlikely the key pledges will be evaluated.

For example, there is no case for saying that the Billion Unit Pledge for alcohol is a success because any gains from people drinking lower alcohol beer have been cancelled out by the increase in people drinking wine and spirits. On these two measures alone, the Responsibility Deals have not achieved their original purpose.

FPH has worked with governments of all political persuasions since it was first founded over 40 years ago. We want to continue to work with Government to improve people’s health. We know that the best way to improve everyone’s health is by working in partnership and we remain committed to doing so. However, we, like other NGOs with limited resources for the important work we do, need to make sure we use our influence and expertise in the most effective way possible. We look forward to continuing our advocacy work and will keep you updated on how it progresses.

In sultry heat, I join a continuous stream of people making their laborious way up the 392 steps to the mausoleum of Dr Sun Yat-sen. It’s beautifully situated on the slope of a wooded mountainside in a huge park in Nanjing, Eastern China.

Everyone is in holiday mood, stopping frequently to rest, drink and take snaps of each other against the backdrop of the splendid double-eaved sacrificial hall built a few years after Dr Sun’s death in 1925.

But as soon as they reach the sarcophagus, absolute silence descends in an atmosphere of deep awe and respect. Dr Sun is a much revered figure, considered to be the ‘Father of the Republic of China,’ honoured by Chinese people on both sides of the Taiwan Strait.

He qualified in medicine at the turn of the century, but soon gave up medicine for politics, plotting the overthrow of the Qing Emperor and helping to establish the fledgling republic. As its inaugural President he extolled three fundamental ‘Principles of the People’ inspired by Abraham Lincoln: One nation of the people – governed by the power of the people – for the welfare of the people.

Back at the conference I’m attending on public health in Asia and the Pacific Rim by the APRU World Institute, I think about the parallels between Dr Sun’s three principles and Michael Marmot’s basic tenets of a healthy society – one that upholds fairness, social justice and the pursuit of wellbeing.

Certainly, health inequalities is a recurring theme at the conference. There are huge disparities between the rich and the poor across the region – and between the cities and rural areas – and this is reflected in the disease patterns observed.

The conference theme is the epidemic of chronic, non-communicable diseases (NCDs) in the tiger economies of east Asia. This part of the world is now going through the escalation of cardiovascular disease we saw in the West about 40 years ago.

But it’s happening so fast here. Urbanisation is rampant – by 2020 China will have over 200 cities each boasting more than a million population. And this is coupled with globalisation, code for westernisation. Nearly every major city has its MacDonalds, KFC and Pizza Hut. Smoking is on a roll – mostly western brands – and in many Asia-Pacific countries, notably China, it’s still allowed in public places.

As to physical activity, whilst it’s true that cycling is still a common means of transport – here in Nanjing for example there are dozens of pushbikes bunched together at the front of the traffic at every stoplight – nevertheless people are increasingly switching to scooters or cars. Air pollution is a big problem in China – not good for the lungs, especially if you’re on a bike. All in all, there can be little surprise that obesity, diabetes, stroke, coronary heart disease, lung cancer and chronic obstructive pulmonary disease rates are rocketing right across the region.

What’s more, although these health problems were first seen most among the better-off – the early adopters of western lifestyles – in recent years the problems have begun to extend down the social gradient, particularly among the urban poor.

Effective prevention and early diagnosis are clearly crucial – yet many Asia-Pacific countries have health systems skewed to favour hospital and specialist services, with little or no investment in health promotion or primary care. Although China for example has well developed communicable disease prevention and control systems, its approach to non-communicable disease is much less robust and its primary care is largely based on private specialists and a vast unregulated army of traditional medicine practitioners.

This pattern is typical of the whole region, and poorer people thus face the double whammy of unhealthy lifestyles plus inadequate access to preventive, diagnostic or curative care. So, despite the best efforts of policymakers to reduce health inequalities in many of the emerging tiger economies of the Asia Pacific, the headlong rush to the cities has meant that the cards are truly stacked against the less well-off.

As in the West, it will take a multisectoral mix of interventions to halt the rising tide of NCDs in these countries – health education, social marketing, regulation of the food and tobacco industries and, above all, health systems change. Marmot argues that efforts should be applied across the social gradient. But from the workers’ high-rises of China’s cities to the slums of Mumbai and the favelas of Rio, there’s also a clear need to focus on the world’s urban poor.

As the conference closes I think again of Dr Sun Yat-sen. I’m sure that, as a medical man, democrat and visionary, he would wish to see public health of the people, by the people, for the people, applied fairly to all the people, not just those who can afford to pay.

The Faculty of Public Health today publishes our joint manifesto on public health, alongside the Royal Society of Public Health. 12 Steps to Better Public Health offers a dozen practical recommendations that, if adopted by the next government, will improve the UK’s health and well-being for the new decade.

The joint public health manifesto calls for:

A minimum price of 50p per unit of alcohol sold

No junk food advertising in pre-watershed television

Ban smoking in cars with children

Chlamydia screening for university and college freshers

20 mph limit in built up areas

A dedicated school nurse for every secondary school

25% increase in cycle lanes and cycle racks by 2015

Compulsory and standardised front-of-pack labelling for all pre-packaged food

Olympic legacy to include commitment to expand and upgrade school sports facilities and playing fields across the UK

Introduce presumed consent for organ donation

Free school meals for all children under 16

Stop the use of transfats

The full manifesto is available to read here, and the front-page Guardian story, with an accompanying podcast from our President Alan Maryon-Davis, is available to read here.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.